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How L.A. County is trying to remake addiction treatment — no more 'business as usual'

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How L.A. County is trying to remake addiction treatment — no more 'business as usual'

Gary Horejsi wrestled with the decision before him, knowing a life could be in his hands.

It was the third time that the woman had used drugs or alcohol since coming to CRI-Help, which runs a 135-bed residential facility in North Hollywood where people are treated for substance use disorder.

CRI-Help needed to be a safe place for people grappling with their addictions. In the past, others had been removed for less. Horejsi, the clinical director, had the final say on whether she should be discharged.

He perused her file on his computer. The woman was still trying, CRI-Help staffers told him. She hadn’t shared drugs with anyone. And if she were to leave, the risks of an overdose were graver than before.

Horejsi decided to let her stay.

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“Things can’t be business as usual anymore,” their chief executive, Brandon Fernandez, later said at a CRI-Help staff meeting. If someone leaves treatment and resumes using drugs the same way they were before, “that could very well look like them dying.”

“So are we going to be willing to do something different?”

“Things can’t be business as usual anymore,” CRI-Help Chief Executive Brandon Fernandez told his staff at a meeting in North Hollywood on April 10.

(Myung J. Chun / Los Angeles Times)

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Fernandez had gathered CRI-Help staff in their North Hollywood conference room to talk about a Los Angeles County initiative that could reshape such decisions. It’s called Reaching the 95% — or R95 — and its goal is to engage with more people than the fraction of Angelenos already getting addiction treatment.

Across the country, more than 48 million people had a drug or alcohol use disorder, according to the latest results from the National Survey on Drug Use and Health. Only 13 million received treatment in the previous year. Among those who did not get treatment, roughly 95% said they did not think that they should.

Those numbers have collided with the grim toll of fentanyl, an especially potent opioid that has driven up deaths across the country. In Los Angeles County, the number of overdose deaths tied to fentanyl skyrocketed between 2016 and 2022, soaring from 109 to 1,910, according to a county report.

“We can’t just take the approach that we’ve been taking and kind of assume that everyone wants the services that we offer,” said Dr. Gary Tsai, director of the Substance Abuse Prevention and Control division at the L.A. County Department of Public Health. “That’s just not the reality.”

His department is trying to nudge addiction treatment facilities to change their approach, by offering financial incentives for those that meet R95 requirements. Among them: changing their rules to not automatically eject people who have a “lapse” of drug use.

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Fernandez, whose organization is participating in R95, said abstinence is still its aspirational goal — and “we still have the ability to use our own clinical judgment on a case-by-case basis,” such as if people endanger other participants. But “we shouldn’t have blanket policies.”

To get R95 funding, they also cannot require people to be totally abstinent before being admitted. And under R95, treatment programs are also being encouraged to partner with syringe programs rooted in “harm reduction” — a philosophy focused on minimizing the harmful effects of drug use — to address the needs of people who may not want to enter or remain in treatment.

Some treatment providers “view us as the enemy instead of as allies,” said Soma Snakeoil, executive director of the Sidewalk Project, which provides Narcan spray to reverse overdoses and other services on L.A.’s Skid Row.

With R95, she said, “the biggest change is that harm reduction organizations and treatment providers are talking to each other in a way that was not happening before.”

A woman wearing gloves gives first aid to a woman on the sidewalk with an open wound on her foot.

Soma Snakeoil, executive director of the Sidewalk Project, gives first aid to a woman with an open wound on her foot last year in Los Angeles.

(Francine Orr / Los Angeles Times)

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The county is also prodding addiction treatment facilities to reexamine whether the way they operate could be turning people away, and look more closely at the “customer experience.” Tsai compared the situation to a restaurant drawing few customers: “How do we get more people in the door?”

Too often, “the drug dealers do a much better job of delivering their product to our patients than we do,” said Dr. Randolph Holmes, chair of government affairs for the California Society of Addiction Medicine.

When Johnny Guerrero decided to get off Skid Row and go into residential treatment in Los Angeles, he was initially turned away because he had arrived “late — maybe 10 minutes late,” the 35-year-old said.

He was only able to get in, he said, because the harm reduction worker who had taken him to the facility let him stay the night at her home, then brought him back the next morning. Even then, “there was so much paperwork. I was so dopesick. There was just hurdle after hurdle after hurdle.”

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“They did not make it easy for an addict to get help,” Guerrero said.

In many cases, “the biggest barrier is just being able to get somebody on the phone” with a treatment provider, said Amanda Cowan, executive director of Community Health Project LA, which provides clean syringes and other services to people who use drugs. “When people are ready, they are ready in that moment.”

As of late March, roughly half of the addiction treatment providers that contract with L.A. County were on track to become “R95 Champions,” which could yield hundreds of thousands of dollars each in additional funding.

A building interior, with a staircase and chairs. In the center two hands hold up a sign reading "We care."

CRI-Help’s George T. Pfleger center in North Hollywood.

(Myung J. Chun / Los Angeles Times)

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To get those funds, they must turn in admissions and discharge policies that adhere to the R95 guidelines, as well as an “engagement policy.” They are also supposed to meet R95 requirements in one other area of their choice, which could include a “customer walkthrough” to see what might turn away clients.

CRI-Help, for instance, had decided to change how it asks newcomers to undergo a search. “The last thing we want to do is trigger someone’s trauma history and potentially have them walk out the door,” Fernandez said.

To ensure it was consistently done with sensitivity, CRI-Help drew up a script for staffers, emphasizing that consenting to a search would help maintain a safe facility. The hope is that “they feel they’re doing something as a part of a community — versus being forced to undergo something that’s uncomfortable.”

Staffers also tell them that if they have any drugs to hand over, “there’s not going to be any consequence, you can still come into treatment,” Fernandez said. “And if we find them on you, there still won’t be any negative consequences.”

The L.A. County push comes as state and federal officials have stressed the need for “low barrier” approaches to addiction care. Even cutting back on drug use can have positive results, researchers have found.

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But some of the changes can be at odds with long-standing beliefs among treatment providers, many of whom got into the field after successfully battling their own addictions in programs firmly focused on abstinence.

Many in the field think “this is what works” because it did work for them, said Vitka Eisen, chief executive of HealthRight 360, another R95 participant. But “we’re the survivors, and we don’t talk to those who didn’t survive.”

Addiction researchers have long called to reexamine how people are treated for substance use disorders. More than a decade ago, a Columbia University center found that “much of what passes for ‘treatment’ of addiction bears little resemblance to the treatment of other health conditions.”

“This is inexcusable given decades of accumulated scientific evidence attesting to the fact that addiction is a brain disease,” the National Center on Addiction and Substance Abuse lamented in its report.

Experts argue that part of the problem is that addiction treatment has long been separated from the rest of the healthcare system. Richard Rawson, senior advisor to UCLA Integrated Substance Abuse Programs, said a major shift was the emergence of buprenorphine, a medication for opioid addiction that could be prescribed in ordinary clinics just like medicines for other chronic conditions.

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But some Southern California treatment providers have viewed using buprenorphine and other such medications as short of sobriety, UC San Diego researchers found — even as California has ushered in requirements for licensed treatment facilities to either offer or help people access such medications.

Addiction is now much more widely understood as a medical condition, but “how much of that philosophy actually gets down to the level of the counselor?” Rawson said. “I think that’s still a work in progress.”

Tsai said a challenge in rolling out R95 is the ingrained idea that “you’re ready or not” for substance use treatment. But “we don’t actually treat any other health condition that way,” he said. “You don’t tell someone with diabetes, ‘Your blood sugar has to be completely under control, and then you’ll be ready for treatment.’”

In North Hollywood, counselors and other CRI-Help employees seated around the conference table studied the R95 goals printed on an L.A. County handout. One staffer said she was struggling with a specific statement, particularly for people in a residential setting: “Requiring abstinence is too high of a bar” for treatment.

Fernandez decided to share his own story. More than a decade ago, he was struggling with drug use, which had worsened after the death of his father. He was unemployed and didn’t have a stable place to live. When an outpatient counselor suggested residential treatment, he initially brushed off the suggestion.

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A person looks over papers while seated at a conference room table

CRI-Help’s staffers had questions and concerns about the changing approach to addiction treatment but ultimately seemed supportive.

(Myung J. Chun / Los Angeles Times)

He changed his mind after a “tough weekend,” but had no intention of abstaining from all drugs in the long term. Fernandez said he was nonetheless welcomed at CRI-Help: “Let’s just help you out for now.”

“I came here begrudgingly with a total attitude that I was going to continue smoking weed when I left treatment. I definitely wasn’t going to stop drinking,” even as he recognized that other things he was doing might be a problem, Fernandez told the CRI-Help employees.

Among those who had gone to treatment, he asked the group, “were you ready for total abstinence on Day One?”

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“No. That wasn’t even my plan,” the same staffer replied with a rueful laugh.

Still, she and others were anxious about how they would keep everyone safe if clients used drugs, especially if they tried to bring them into the facility. “That worries me a little bit,” she said.

“It worries me too,” Fernandez said.

What preoccupies CRI-Help staff is how to balance the needs of people who have had a “lapse” into drug use with maintaining a safe environment for other clients grappling with addiction.

Horejsi said in an interview that whenever someone uses — even if they don’t share their drugs — “everyone knows, and that in itself does have an effect on people. Sometimes people will feel less safe.”

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But Horejsi stressed to the group that “we’re already not discharging people for using” alone.

When people have relapsed, the North Hollywood center has monitored them one-on-one in its television room until staff are sure they are safe, then decided on their next steps. Some have ultimately been moved to another CRI-Help residential facility to continue getting treatment and have a “fresh start,” he said.

The clinical director also urged his co-workers to look back at the many changes CRI-Help had already undergone, such as starting to offer medication for addiction treatment. He reminded them that years ago, CRI-Help clients could be discharged if a doctor had given them an opioid pill at the hospital.

A woman speaks

Mary Grayson, a longtime staff member at CRI-Help, spoke positively of the organizations changes over the years.

(Myung J. Chun / Los Angeles Times)

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“What about when we discharged people because they talked about getting — they glorified drugs?” said Mary Grayson, a longtime CRI-Help employee.

Leaning forward in her seat, Grayson reminded her co-workers that “CRI-Help is not what it was when I walked through those doors 25 years ago — thank God!”

It started with “two shacks on this property. Two raggedy shacks. And look at where we are now,” she said. “Without us changing and growing, we won’t be able to be who we are.”

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Opinion: Most older Americans who need hearing aids don't use them. Here's how to change that

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Opinion: Most older Americans who need hearing aids don't use them. Here's how to change that

Having depended on hearing aids for nearly three decades, I’m astounded by the lack of Medicare coverage for devices that can solve a problem afflicting tens of millions of older Americans.

Nearly two-thirds of Americans over age 70 have some degree of hearing loss, and over half of those 75 and older experience impairment serious enough to be considered disabling. But most don’t wear hearing aids.

Because the legislation that created Medicare nearly 60 years ago specifically excluded hearing aids, those who rely on the program’s traditional coverage must pay for them out of pocket. That expense is among the chief barriers to wider use of the devices.

Age-related hearing loss impedes basic communication and the relationships that depend on it. Expanded access to hearing aids could therefore do no less than enable more older Americans to establish and maintain the social connections that are essential to a meaningful life.

Hearing loss is like an invisible, muffling curtain that falls in front of anyone speaking. Asking people to repeat themselves can yield irritated and hurtful responses. And it’s hopeless to ask a soft-spoken person to speak up. Sometimes it’s easier just to nod and smile.

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Many older people I know choose to avoid social gatherings altogether because they can’t hear well. Without hearing aids, I’d stay home too.

Hearing loss can harm one’s health in other ways. For example, I’ve written about the need for a comprehensive approach to reducing cancer risk at older ages, including preventive services such as colorectal cancer screening. But these services rely on conversations between patients and their healthcare providers. An older patient’s ability to hear and understand such conversations shouldn’t be taken for granted or ignored.

The Food and Drug Administration did improve access to hearing aids by making some of them available without a prescription in 2022, but the over-the-counter devices are inadequate for serious hearing loss like mine. My private health insurance, meanwhile, started covering hearing aids a few years ago, providing up to $2,500 for them every five years. One hearing aid alone can cost that much or more, however.

Despite its limitations, my private coverage for hearing aids is better than nothing, which is what traditional Medicare provides.

Hearing loss is more common among lower-income people and those without advanced education. The toll from noisy workplaces compounds age-related hearing loss for some. One analysis found that most Americans with a serious hearing disability can’t afford the typical price of hearing aids.

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Many of the older adults who can’t come up with these significant out-of-pocket expenses spent their working years in low-wage jobs that our country depends on. Denying them treatment for their hearing loss is a lousy way to treat people who gave years of service to our society.

Although some older adults with hearing loss won’t benefit from hearing aids, Medicare coverage for the devices might encourage more beneficiaries to get their hearing tested so they can get the treatment that’s right for them. And while Medicare coverage alone won’t address the stigma some people associate with hearing aids, the availability of newer, more comfortable and less obvious technology might win over some refuseniks.

Legislation reintroduced with bipartisan support last year would finally correct this glaring gap in Medicare coverage by removing the hearing aid exclusion from the law. There’s no reason to delay action on this any longer. Are our representatives listening?

Mary C. White is an adjunct professor of environmental health at Emory University’s Rollins School of Public Health, a Public Voices fellow at AcademyHealth in partnership with the OpEd Project and a former federal epidemiologist.

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Second human case of bird flu detected in Michigan dairy worker

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Second human case of bird flu detected in Michigan dairy worker

A second human case of bird flu in a diary worker has been confirmed in Michigan, state and federal health officials announced Wednesday.

The symptoms were mild, consisting of conjunctivitis. The Texas dairy worker who contracted the virus in March also came down with pink eye.

At a press call on Wednesday, Nirav Shah, principal deputy director of the U.S. Centers for Disease Control and Prevention, said the finding was “not unexpected” and that it was a scenario “that we had been preparing for.”

He said that since the discovery of H5N1 in dairy cattle, state and federal health officials have been closely monitoring farmworkers and slaughterhouse workers and urging farmers and farmworker organizations to “be alert, not alarmed.”

Federal officials say they still believe the human health risk of bird flu is low; however, it underscores the need for people who are interacting with infected or potentially infected farm animals or birds to take precautions, including avoiding dead animals and wearing personal protective equipment (PPE) if there’s a need to be in close contact.

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Though a nasal swab from the person in Michigan tested negative for influenza, an eye swab from the patient was shipped to the CDC and tested positive for influenza A(H5N1) virus.

This is the third case of H5N1 reported in the United States. A poultry worker in Colorado was identified in 2022.

Although the symptoms in the three farmworkers in the U.S. have been mild, people elsewhere in the world have suffered more severe illness, including death. According to the World Health Organization, between Jan. 1, 2003, and March 28, 2024, there have been 888 cases of human infection from 23 countries; 463 were fatal.

In preparation for a more widespread outbreak, the CDC updated its guidance for PPE in dairies and issued a nationwide order for healthcare providers to be on the lookout for novel influenza.

On Tuesday, the CDC asked clinical laboratories and health departments to increase the number of influenza samples being analyzed “to maximize the likelihood of catching a case of H5N1 in the community,” Shah said.

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The US Department of Agriculture is also expanding its surveillance and support by providing $1500 to non-infected farms to beef up biosecurity, and $100 to producers who want to buy inline samplers to test their milk. The agency will also provide $2000 per farm to cover veterinary fees for testing, as well as shipping costs to send those tests to laboratories for analysis.

There have been no cases of H5N1 detected in California’s dairy herds.

Officials said ongoing analysis of the nation’s dairy supply suggests it is safe to consume, Despite the risk to human health being low, an official with the Administration for Strategic Preparedness and Response said it will make Tamiflu available upon request “to jurisdictions that do not have their own stockpile and are responding to pre-symptomatic persons with exposure to confirmed or suspected infected birds, cattle or other animal exposures.”

Dawn O’Connell, assistant secretary of the preparedness agency, said it started the “fill and finish” process for approximately 4.8 million doses of vaccine “that is well matched to the currently circulating strain of H5N1 through the national pre-pandemic influenza vaccine stockpile program.”

She said the decision to get started on H5N1 vaccines was not a response to any heightened concern, but since it takes several months to fill and finish vaccine doses, the agency “thought it made sense given what we were seeing.”

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Gas stoves may contribute to early deaths and childhood asthma, new Stanford study finds

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Gas stoves may contribute to early deaths and childhood asthma, new Stanford study finds

Lung-irritating pollution created by cooking with gas stoves may be contributing to tens of thousands of premature deaths and cases of childhood asthma in the United States, according to a new study published in the journal Science Advances.

For decades, scientists have known the flames from a gas stovetop produce nitrogen dioxide, a pungent gas that can inflame a person’s lungs when inhaled. But for the first time, a team of researchers from Stanford University and Oakland-based research institute PSE Healthy Energy published a nationwide estimate of the long-term health consequences associated with cooking with natural gas and propane stoves.

Researchers concluded that exposure to nitrogen dioxide emissions alone may contribute to nearly 19,000 premature deaths in the United States each year. It has also resulted in as many as 200,000 current cases of pediatric asthma compared with cooking with electric stoves, which do not produce nitrogen dioxide.

Aggressive and impactful reporting on climate change, the environment, health and science.

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Stanford researcher Yannai Kashtan noted higher levels of pollution were correlated with the amount of gas that was burned. But pollution also accumulated at higher levels inside smaller homes.

“If you live in a smaller house, you’re exposed to more pollution, and that can lead to income and racial disparities in exposure,” Kashtan said. “In general, folks living in neighborhoods with higher levels of outdoor pollution also tend to have higher indoor pollution. So this environmental injustice extends indoors as well.”

The American Gas Assn., a trade organization representing more than 200 local energy companies nationwide, dismissed the findings as “misleading and unsupported.”

“Despite the impressive names on this study, the data presented here clearly does not support any linkages between gas stoves and childhood asthma or adult mortality,” the association’s president and CEO, Karen Harbert said in a statement earlier this month.

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The study is the latest examining the serious health effects associated with breathing fumes from gas stoves, which release planet-warming carbon emissions and a variety of air pollutants. In recent years, the popular household appliance has become a political hot-button issue as policymakers and regulators have weighed environmental impacts against consumer choice.

Many large cities in California, including Los Angeles, have moved toward phasing out gas stoves in newly constructed residences. Earlier this month, the California Assembly advanced a bill to the Senate that would require gas stoves to come with warning labels detailing the pollution and health effects that can arise from cooking with gas.

Gas stoves emit a variety of pollutants, including asphyxiating carbon monoxide, cancer-causing formaldehyde and benzene. The flame also creates nitrogen dioxide, a precursor to smog and a pollutant that can cause difficulty breathing.

Environmental groups say consumers should be notified about these pollutants and the potential harm they can cause.

“Gas stoves create pollution in our homes, increasing the risk of childhood asthma and other respiratory problems for our families,” said Jenn Engstrom, state director for California Public Interest Research Group. “However, this risk has largely been hidden from the public. Consumers deserve the truth when it comes to the danger of cooking with gas. Warning labels will give consumers what they need to make informed decisions when they purchase appliances for their homes.”

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Kashtan and other researchers had previously discovered cooking with gas stoves presented a similar cancer risk as inhaling second-hand cigarette smoke. They also found some gas stoves leaked contaminants even when the burners were off.

The effects are especially devastating to children, whose smaller and still-developing lungs need to take more breaths than adults, Kashtan said. Older adults, especially those with cardiovascular or respiratory illness, are also more vulnerable to pollution from gas stoves.

To alleviate indoor air pollution, experts recommend using ventilation hoods and opening windows while cooking,

Starting in 2008, California required new and redeveloped homes to have ventilation that could prevent pollution from building up indoors. But during their research, measuring emissions in more than 100 households across the country, Yannai said they found many kitchens didn’t have ventilation hoods at all.

Although the health effects of breathing these pollutants are clear, researchers still wonder to what degree these conditions could be reversible. As communities take steps to mitigate their exposure or transition away, he said we could soon see the results.

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“It’s never too late to stop breathing in pollution,” he said.

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